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Session ID: 1005-14 Friday, June 20, 2014

Xavier F. Amador, PhD 1

“I am Not Sick, I Don’t Need Help!”“I am Not Sick, I Don’t Need Help!”

Research on poor insight and how we can help using LEAP®

American Psychiatric Nurses AssociationClinical Psychopharmacology Institute

June 20, 2014

Xavier Amador, Ph.D.Director, LEAP Institute

www.LEAPinstitute.org

Poor insight and relationships

© LEAP Associates, LLC, 2013

“Denial” of illness in the news

Amador et al. Schizophr Bull.1991;17:113–132; Amador.

I am not sick, I don’t need help! How to help someone with mental

illness accept treatment. New York: Vida Press; 2007

…news stories involving such persons appear nearly every day.

• Poor insight into schizophrenia and bipolar disorder is so common…




Colorado Theatre Shooting


The Unabomber – Ted Kaczynski

• More “denial” in the headlines

Amador XF, Reshmi P.Defending the Unabomber: anosognosia and schizophrenia. Psychiatric Quarterly. 2000; 71(4): 363-370.


“Denial” of illness

• Denial impairs common-sense judgment about the need for treatment and services. Yes?– But are we dealing with denial?

“Anosognosia”

Diagnostic and Statistical Manual of Mental Disorders. 4th ed (Text Revision). Washington, DC, APA, 2000.




Unawareness of mental disorderDSM-IV field-trial–study patients with schizophrenia (n=221)

Missing data 1.9%

ModeratelyUnaware25.3%

Aware40.7%

Unaware32.1%

Amador XF, et al. Arch Gen Psychiatry. 1994;51(10):826–836.


Unawareness of mental disorder

Amador XF, et al. Arch Gen Psychiatry. 1994;51(10):826–836.


Other problems with “insight”

50% of patients with schizophrenia are unaware of having Tardive Dyskinesia

Rosen, et al. American Journal of Psychiatry. 1982.Tremeau, et al. Schizophrenia Research. 1997. Arango, et al. Schizophrenia Research. 1999.Caracci, et al. American Journal of Psychiatry. 1990.




The problem with oral antipsychotic medications

• Between 50% and 75% of patients with schizophrenia exhibit full or partial nonadherence to pharmacological treatment (Rummel-Kluge, 2008)

• Within 7 to 10 days of medication initiation (Keith & Kane, 2003) – 25% are noncompliant

– 50% are off medication after 1 year

– Up to 75% after 2 years

• Approximately 33% reliably take medication prescribed (Oehl, 2000)


Insight and adherence

• Awareness of being ill (insight) is among the top 2 predictors of long-term medication adherence

• What is the other top predictor?– Relationship with someone who:

• Listens to you without judgment• Respects your point of view• Believes you would benefit from treatment


Insight and adherence

• We never “win” on the strength of our argument, we win on the strength of our relationship.




Insight and adherence…

www.LEAPInstitute.org

What causes poor insight

Psychological defense?

“Cultural” and/or education?

Neuropsychological deficits?

DSM-IV-TR™ Schizophrenia and other psychotic disorders

Drs. Xavier Amador and Michael Flaum, co-chairs

• A majority of individuals with schizophrenia have poor insight regarding the fact that they have a psychotic illness. Evidence suggests that poor insight is a manifestation of the illness rather than a coping strategy.

• It may be comparable to the lack of awareness of neurological deficits seen in stroke, termed anosognosia.

• This symptom predisposes the individual to noncompliance with treatment and has been found to be predictive of higher relapse rates, increased number of involuntary hospital admissions, poorer psychosocial functioning, and a poorer course of illness. (page 304)

Diagnostic and Statistical Manual of Mental Disorders. 4th ed (Text Revision). Washington DC, APA, 2000.



DSM-V™ Schizophrenia and other psychotic disordersDr. William T. Carpenter. Chair (Text submitted by Dr. Xavier Amador)

• Unawareness of illness is typically a symptom rather than a coping strategy. It is comparable to the lack of awareness of neurological deficits following brain damage, termed anosognosia.

• This symptom is the most common predictor of nonadherence to treatment. It has been found to predict higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and a poorer course of illness. (page 101)

Diagnostic and Statistical Manual of Mental Disorders. 5th ed.. Washington DC, APA, 2013.


Anosognosia is similar

Very severe lack of awareness

Confabulations are common

The belief persists, despite conflicting evidence


Anosognosia for mental illness: What it feels like.



When dealing with anosognosia for mental illness…

• The “doctor knows best” approach does not work, because collaboration is a goal, not a given

Do not expect:• Gratitude• Receptiveness• Adherence

Do expect:• Frustration and anger• Suspiciousness• Overt and secretive “non-compliance”


When dealing with anosognosia for mental illness…

Long-Acting Treatments (LAT’s) are indicated:

• 50% on orals stopped medication compared to only

• 17% on long-acting injections– But how can you offer a LAT in a manner that is likely to lead to

acceptance and partnering long-term?

• LEAP and related approaches

Keith & Kane. J Clin Psychiatry 2003;64:1308–1315; Young et. Al., 1999; Zygmunt et al. Am J Psychiatry 2002;159:1653–1664



Motivational interviewing: Studied extensively in patients with substance abuse disorders

• Interventions to Improve Medication Adherence in Schizophrenia1

• Reviewed studies from 1980 through 2000

• “Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective”

• “Motivational techniques [such as LEAP] were common features of successful programs”

Please see LEAPInstitute.org “Research” for additional evidence.• Zygmunt, et al. Am J Psychiatry. 2002;1653-1664.



LEAP

• The LEAP approach– Listen

– Empathize

– Agree

– Partner

2000

2007

2008

Based on MAIT, Amador & Beck.


Over the past 10 years LEAP has taught to tens of thousands globally (EU, USA, Asia Pacific)


ListenLEAP: Listen, Empathize, Agree, Partner

• Reflectively to:

Delusions

Anosognosia

Desires

ListenLEAP: Listen, Empathize, Agree, Partner

• Why do we resist reflecting back many important things our patients tell us?– We fear we will make “it” worse (ie, delusions, insight, attitudes

about medication, etc)

– We do not want to be asked to do something we cannot

– We worry about injuring the therapeutic alliance

– We fear we have to be dishonest




LEAP: Listen, Empathize, Agree, Partner

How to delay giving your opinion

• “I promise to answer your question. If it’s alright with you, I would like to first hear more about _________. Okay?”

• “I will tell you what I think. I would like to keep listening to your views on this, because I am learning a lot I didn’t know. Can I tell you later what I think?”

• “I will tell you. But, I believe your opinion is more important than mineand I would like to learn more before I tell you my opinion. Would that be okay?”


When you finally give your opinion, use the 3 AsLEAP: Listen, Empathize, Agree, Partner

Apologize• “I want to apologize, because my views

might feel hurtful or disappointing”

Acknowledgefallibility

• “Also, I could be wrong. I don’t know everything”

Agree• “I hope that we can just agree to

disagree. I respect your point of view and I hope you can respect mine”


EmpathizeLEAP: Listen, Empathize, Agree, Partner

• Strategically express empathy for:– Delusional beliefs

– Desire to prove “I’m not sick!”

– Wish to avoid treatment

• Normalize the experience




AgreeLEAP: Listen, Empathize, Agree, Partner

• Discuss only perceived problems and goals• Review advantages and disadvantages of adherence

• Reflect back and highlight the perceived costs and benefits

AGREE TO DISAGREE


PartnerLEAP: Listen, Empathize, Agree, Partner

ou

both

agree

can

you

both

agree

Move forward on goals you both agree can be worked on together


The 7 LEAP TOOLSLEAP: Listen, Empathize, Agree, Partner

• Listen• Empathize• Agree• Partner

• Delay• Opinion (3 A’s)• Apologize





• LEAP Practitioner Level-I Trainings

LEAP® LP-I Trainings in Turkey


Therapeutic Alliance Program: LP-I Trainings• Results of LEAP® Trainings in Turkey (April-June 2010)

20 psychiatrist trainings

1 psychiatric nurse training

Over350 physicians

Over 200 nurses 50 family

caregivers


LEAP® LP-I trainings




LEAP LP-I Trainings: Psychiatrists polled (n = 226) • Comprehensive surveys are completed by participants after each training

Overall satisfaction about the training

Comparison with the pharma-sponsored meetings

Evaluation about the content of the training

*The content of the training is up to date

*The content of the training is relevant to my daily practice

*The content of the training is useful

*The adequacy of the time spend on role plays is enough

Evaluation of the trainer

Evaluation of the training materials

Evaluation of the training rooms


LEAP LP-I Training: Psychiatrists polled (n =226)• Would you recommend “LEAP® Training” to your colleagues?

Yes

Don't know

No

3% 0%

97%

97%


LEAP LP-I Training: Psychiatrists polled• Would you like to attend similar trainings?

Absolutely

Yes

Maybe

No

3%

54%

3%

43%




LEAPLEAP: Listen, Empathize, Agree, Partner

THANK YOU!

Feel free to visit www.LEAPinstitute.org

For free training resources and so we can support your work.

Documents

“I am Not Sick, I Don’t Need Help!” - Log into your ...eo2.commpartners.com/users/apna_kc/downloads/1005-Color.pdf · I am not sick, I don’t need help! How to help someone